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New report charts brain injury risk of critical care blood sampling system

Critical care patients could be at risk if the wrong type of fluid is used to flush an arterial line – a system that is used to monitor blood pressure and glucose levels – says our latest report.
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HSIB marks first World Patient Safety Day

Along with many healthcare organisations across the globe, we are celebrating the first ever World Patient Safety Day on 17 September and highlighting the work we do to improve patient safety across …
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Gap in care for chronically ill prisoners

Prisoners are at risk of being transferred without crucial medication, according to our latest healthcare safety investigation report.
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New investigation looks at the procurement, usability and adoption of ‘smart’ pumps

HSIB have launched an investigation after being notified of three incidents where an accidental fentanyl overdose occurred. The Trust had administered the powerful pain medication using a ‘smart’ inf…
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Bulletin on progress in our high-risk prescribing errors investigation is released

The Healthcare Safety Investigation Branch (HSIB) has published an interim bulletin for its investigation looking at identifying and reducing high-risk prescribing errors in hospital.
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Latest HSIB report focuses on technology to reduce risk of X-ray findings getting lost

A report published today (18 July) by HSIB showcases where technology could play a pivotal role in reducing harm caused by failures in communication or follow-up of unexpected significant radiologica…
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New investigation looks at delayed recognition of retained vaginal swabs and tampons following childbirth

HSIB has launched an investigation into the delayed recognition of retained vaginal swabs and tampons following childbirth.
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Interim bulletin released relating to the lack of timely monitoring of patients with glaucoma

We have released an interim bulletin relating to the lack of timely monitoring of patients with glaucoma.
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HSIB issues recommendations to prevent ‘devastating’ deaths from button/coin cell batteries

In our latest report (published 27 June) we have put forward a number of safety recommendations to prevent serious injuries or death from the unknown ingestion of button/coin cell batteries.
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National Patient Safety Alert Committee responds to HSIB safety recommendation

We made a safety recommendation to the National Patient Safety Alert Committee as a result of our investigation into the piped supply of medical air and oxygen.
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Notification of investigation: wrong patient details on blood sample

The HSIB was notified of an incident where a patient’s blood sample was incorrectly labelled with another patient’s details. HSIB has launched an investigation regarding incorrect patient details bei…
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Notification of investigation: undiagnosed cardiomyopathy in a young person with a learning disability

The HSIB was notified of an incident where a young patient with undiagnosed cardiomyopathy died following an anaesthetic which was needed to facilitate a Magnetic Resonance Imaging (MRI) scan. The pa…
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Dr Stephen Drage joins HSIB as director of investigations

We’ve appointed a new director of investigations to lead the continued delivery of our national investigations programme.
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Notification of investigation: lack of timely monitoring for patients with glaucoma

The HSIB was made aware of a woman who was referred to hospital eye services for urgent assessment of glaucoma.
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Interim bulletin released relating to the management of VTE risk in patients following thrombolysis for an acute stroke

We have released an interim bulletin relating to the management of Venous Thromboembolism (VTE) risk in patients following thrombolysis for an acute stroke.
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HSIB’s family engagement approach nominated for prestigious patient safety award

Our innovative model of family engagement has been nominated in the ‘best emerging solution for patient safety’ category at the 2019 HSJ Patient Safety Awards.
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HSIB investigation tackles national complexity of medicine safety

Our latest report published 11 April 2019, emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk.
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Interim bulletin released relating to the potential under-recognised risk of harm from the use of propranolol

We have released an interim bulletin relating to the potential under-recognised risk of harm from the use of propranolol. Interim bulletins are released to share further details of each investigation…
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Notification of investigation: recognition of the acutely ill infant

The HSIB was notified of a three-month-old infant who was admitted in to a hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococ…
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HSIB’s maternity investigation programme completes rollout into 130 NHS trusts

From today, all trusts in England will be referring maternity cases to HSIB.From 1 April 2018, we became responsible for the investigations of maternity incidents that met the criteria for the Each B…
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New report focuses on design and implementation of patient safety alerts

Our latest report, published 28 February 2019, highlights that despite ongoing work, NHS trusts may face barriers when responding to national patient safety alerts.
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Notification of investigation: potential under-recognised risk of harm from the use of propranolol

The HSIB was notified of a patient who died following an overdose of propranolol.
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Notification of investigation: management of VTE risk in patients following thrombolysis for an acute stroke

The HSIB was notified of a patient who suffered an pulmonary embolism while under the care of an acute stroke unit.
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HSIB’s innovative approach ensures families are central to safety investigations

Both national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations.
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New report focuses on recommendations to make ambulance transfers safer

Our new report, published 24 January 2019, shows that a lack of national guidance and standard practice for ambulance transfers could be putting patients at risk.
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HSIB release interim bulletin relating to the management of chronic health conditions in prisons

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to the management of chronic health conditions in prisons.
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Electronic prescribing and medicines administration systems interim bulletin released

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to the investigation into electronic prescribing and medicines administration systems and safe discharge.
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Beware of button batteries this Christmas

We are calling for vigilance to the dangers of button batteries to children this Christmas. Parents and families should be aware of the potential harmful effects of button batteries if swallowed.
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Notification of investigation: piped supply of medical air and oxygen

The Healthcare Safety Investigation (HSIB) has launched a new investigation after an incident where a patient was connected to the medical air supply instead of the oxygen supply.
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HSIB report calls for better regulation of medical devices

Our new report published today has highlighted the high patient risk – with even possible risk of death - associated with some medical devices used within the NHS for patient care and treatment.
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HSIB national report reinforces need for 24/7 emergency mental health care

The Healthcare Safety Investigation Branch (HSIB) has today published its latest report highlighting the variation in mental health care across emergency departments and setting out four recommendati…
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HSIB places emphasis on effective system design and standardisation of practice to tackle common never event

The Healthcare Safety Investigation Branch (HSIB) has today published its latest report,highlighting why current measures aren’t effective in preventing the insertion of an incorrect intraocular lens…
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HSIB release interim bulletin relating to ectopic pregnancy investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation into the diagnosis of ectopic pregnancy.
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Notification of investigation: high risk medicines administration in hospital to frail older people

The Healthcare Safety Investigation Branch has launched an investigation into an incident where a hospital inpatient was administered repeated doses of warfarin in error and suffered significant harm…
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Notification of investigation: the diagnosis and management of ectopic pregnancy

Following an initial investigation into the care of a patient who had a ruptured fallopian tube following a delay in diagnosis of an ectopic pregnancy, the Healthcare Safety Investigation Branch (HSI…
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Notification of investigation: management of chronic health conditions in prisons

The HSIB has launched an investigation regarding the management of chronic health conditions in prisons.
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Notification of investigation: EPMA systems and safe discharge

The Healthcare Safety Investigation Branch has launched an investigation into an incident where a patient was inadvertently prescribed and administering two anticoagulation medications.  This occurre…
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HSIB release interim bulletin relating to button battery investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation into Button Battery Ingestion.
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HSIB release interim bulletin relating to radiological findings investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation into the communication and follow-up of unexpected significant radiological findings.
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HSIB publishes latest report - administering a wrong site nerve block

The Healthcare Safety Investigation Branch (HSIB) has today published an investigation report relating to a never event, the administering of a wrong site nerve block. 
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Notification of investigation: communication and follow up of significant unexpected radiological findings

The Healthcare Safety Investigation Branch (HSIB) has launched a full investigation into a case where a patient’s chest x-ray, showing a possible lung cancer, was not acted upon.
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HSIB publish annual review

The Healthcare Safety Investigation Branch (HSIB) has today published its annual review.  Focusing on HSIB’s role in shaping a safer healthcare system, the review charts HSIB’s progress over the past…
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HSIB release interim bulletin relating to testicular torsion investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the management of early onset testicular pain.
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Notification of investigation: ingestion of button batteries in children

The Healthcare Safety Investigation Branch has launched an investigation following a referral regarding a child who died following an unknown and undetected ingestion of a button battery.
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HSIB second national investigation report: CAMHS to AMHS

Today, the Healthcare Safety Investigation Branch has published its second full investigation report to support a new learning culture around mistakes in the NHS.
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Notification of investigation: primary management of acute onset testicular pain

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation following a referral regarding a patient who suffered the loss of a testicle after a missed testicular torsion.
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Chief Investigator's statement - wrong prosthesis report

This first report is the culmination of many months of rigorous and independent investigation, working closely with those involved in the incident, as well as relevant organisations and subject matte…
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HSIB report reinforces national approach to tackle preventable deaths from deterioration

Our latest report, published 23 May 2019, recommends tackling the recognition and response to deteriorating patients with the same national approach driving improvement in identifying and treating se…
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HSIB release interim bulletin relating to wrong lens investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the insertion of an incorrect intraocular lens.
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